Games for the Physically Challenged
350 New Campus Drive
Brockport, NY 14420
Phone: 585-395-5620
Fax: 585-395-2310
smaxwell@brockport.edu
Dear Group Leader,
Thank you for your interest in volunteering for the Camp Smile Empire State Games for the
Physically Challenged. The Games will take place on Friday, October 16th and Saturday,
October 17th, 2015 at SUNY Brockport, SERC & Tuttle North Athletic Complex. Please review
the information on this sheet, fill out the enclosed group volunteer information form, the group
volunteer sign up form and the student volunteer insurance/waiver forms.
1. Please insure that all volunteers are 16 years of age or older, unless otherwise
cleared by the Games office.
2. Student groups must have adequate adult supervision while at the Games site.
3. Volunteers will receive a T-shirt that they are required to wear.
4. Volunteers should dress appropriately and according to the weather of the day,
be prepared for anything, as events will be outdoors on Friday.
5. The provided lunch will consist of hotdogs/Friday and hamburgers/Saturday.
Anyone requiring a special diet must bring his or her own lunch.
6. The group coordinator should check in for the group, and pick up ID tags
and shirts at the Volunteer Registration in TN Gym 206.
7. Please return the Group Volunteer forms by October 2nd, 2015. Each volunteer
must fill out an insurance/waiver/medical form in order to volunteer. Each form
requires a parent/guardian signature. You may bring these forms with you to the
volunteer registration table on Friday, October 16th.
If you have any questions, please contact:
Susan Maxwell at the Games Office at (585) 395-5620
Or by email at smaxwell@brockport.edu.
Visit our website at: www.empirestategamesny.com
Empire State Games for the Physically Challenged
SUNY Brockport
October 16 & 17, 2015
Group Volunteer Information Form
School or Group _________________________________________________________
Address _______________________________________________________________
City _______________________________________ State ______ Zip ____________
Contact Person _________________________________________________________
Phone Number _____________________ Cell Phone___________________________
Email:_________________________________________________________________
Volunteer options:
Friday, October 16th:
Buddies (9am – 2pm)
_____
(work 1 on 1 with an athlete)
Demonstrations
_____
(assist with demo games/activities)
_____
(assist with set up and run event)
Buddies (9am – 2pm)
_____
(work 1 on 1 with an athlete) (Limited number needed)
Swimming
_____
(assist with swimmers in pool & timers)
Slalom
(9am – 2pm)
(9am – 2pm)
Saturday, October 17th:
(9am – 12noon)
Registration Deadline: October 2, 2015
There are a limited number of volunteer positions to be filled.
Positions will be filled as registrations are received. All others will be asked to
participate as boosters, cheering on the athletes. Due to the large number of groups,
there is a limit of 25 volunteers per group.
Empire State Games for the Physically Challenged
School Group Volunteer Form
SUNY College at Brockport - October 16 & 17, 2015
“Celebrating 29 Years of Ability”
Name (PRINT NEATLY)
Total T-Shirt Count:
M: _____
L: _____
Date of Birth
XL: _____
T-Shirt Size
XXL: _____
Teacher/Chaperone Name: ______________________________________
School/Group Name: __________________________________________
Mailing Address:______________________________________________
Contact Phone #: (____)_____________Fax: (____)_________________
Email:______________________________________________________
2015 Games for the Physically Challenged Student Group Volunteer Waiver and Release Form
Volunteer Name (print): ____________________________________________________________________________________
Please answer all questions:
1. Have you volunteered for the Games in the past? ____Yes ____No
If yes, tell us how long _________________________________________________________________________________________________
What Committees? ____________________________________________________________________________________________________
2. List any medical conditions, disabilities, etc. which might affect your assignment:____________________________________________________
3. Except for minor traffic violations, have you ever been convicted of a violation of the law? (a yes answer does not necessarily preclude you from
volunteering with CSESGPC) _____No
_____Yes
If Yes, please list the violation(s) or crime(s) of which you were convicted and the date(s) of the convictions below:
__________________________________________________________________________________________________________________________
4. Are you currently on parole or probation? _____No
_____Yes - If yes, please explain:
__________________________________________________________________________________________________________________________
5. Are you currently awaiting trial on any criminal charge? _____No
_____Yes - If yes, please explain:
__________________________________________________________________________________________________________________________
6. Are you currently on deferred adjudication? _____No
_____Yes - If yes, please explain:
__________________________________________________________________________________________________________________________
7. Have you been discharged or asked to resign from any position in the past 5 years? _____No
_____Yes - If yes, please explain:
__________________________________________________________________________________________________________________________
Background Check Consent
I hereby authorize Camp Smile Inc. to make such investigations and inquires of my employment and background as may be necessary in arriving at a
volunteer position with the Camp Smile Empire State Games for the Physically Challenged.
Waiver & Medical Release
I hereby release and forever discharge any and all rights and claims for damages, including any claims, for loss, damages or injury to my person or
property arising out of the performance or failure of performance of the Camp Smile Inc., the State of New York, the New York State Office of Parks,
Recreation, and Historic Preservation, the owner of the site of competition I am volunteering at, or the respective officers, agents, representatives,
successors and/or assignees of the parties named above, from any and all claims, demands and liability of every kind and nature, legal or equitable
occasioned by or arising out of my volunteering for the event known as the Camp Smile Empire State Games for the Physically Challenged.
I recognize the challenges of the event(s) in which I have chosen to volunteer and I assume all risks of personal injury or death in connection therewith.
I attest that I am sufficiently physically fit to participate safely therein, and that a qualified medical person has not advised me otherwise. I hereby
consent to allow my picture or likeness to appear in any official documentary, sponsor advertisement or exclusive television coverage of the Camp
Smile Empire State Games for the Physically Challenged programs in any manner incidental to my participation in the Camp Smile Empire State
Games for the Physically Challenged and without compensation to me.
I hereby authorize any first aid, medication, medical treatment, or surgery deemed necessary in case of emergency. I also authorize the attending
medical person to execute on my behalf any permission forms and other appropriate medical documents on my behalf if I am not immediately available
to do so. I understand that I am responsible for any charges incurred by me or on my behalf for medical treatment.
I hereby agree that I will abide by the code of conduct as stated in the Camp Smile Empire State Games for the Physically Challenged Handbook, and if
failing to do so, will abide by any penalties as stipulated by such.
By signing below, I certify that I have read the statements above, and agree to the terms stated therein.
________________________________________________________________________________
Signature (all applicants must sign here)
___________________
Date
Under age 18 Parent/Guardian Permission: By signing below, I certify that I am the parent or legal guardian of the applicant and have read the above
content and the information provided, agree to the terms on behalf of the applicant, and grant permission for him/her to volunteer for the Camp Smile
Empire State Games for the Physically Challenged.
________________________________________________________________________________________
Signature of parent/guardian (parent/guardian must sign if applicant is under age 18)
___________________
Date
Return both pages of the completed form by October 2, 2015 to:
Games for the Physically Challenged, Susan Maxwell, SUNY College at Brockport,
350 New Campus Drive, Brockport, NY 14420
Or fax both pages to 585-395-2310